HB1193 EngrossedLRB097 05476 RPM 45536 b

1    AN ACT concerning insurance.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Insurance Code is amended by
5changing Section 368d as follows:
 
6    (215 ILCS 5/368d)
7    Sec. 368d. Recoupments.
8    (a) A health care professional or health care provider
9shall be provided a remittance advice, which must include an
10explanation of a recoupment or offset taken by an insurer,
11health maintenance organization, independent practice
12association, or physician hospital organization, if any. The
13recoupment explanation shall, at a minimum, include the name of
14the patient; the date of service; the service code or if no
15service code is available a service description; the recoupment
16amount; and the reason for the recoupment or offset. In
17addition, an insurer, health maintenance organization,
18independent practice association, or physician hospital
19organization shall provide with the remittance advice, or with
20any demand for recoupment or offset, a telephone number or
21mailing address to initiate an appeal of the recoupment or
22offset together with the deadline for initiating an appeal.
23Such information shall be prominently displayed on the

 

 

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1remittance advice or written document containing the demand for
2recoupment or offset. Any appeal of a recoupment or offset by a
3health care professional or health care provider must be made
4within 60 days after receipt of the remittance advice.
5    (b) It is not a recoupment when a health care professional
6or health care provider is paid an amount prospectively or
7concurrently under a contract with an insurer, health
8maintenance organization, independent practice association, or
9physician hospital organization that requires a retrospective
10reconciliation based upon specific conditions outlined in the
11contract.
12    (c) No recoupment or offset may be requested or withheld
13from future payments 18 months or more after the original
14payment is made, except in cases in which a court, government
15administrative agency, or other tribunal has made a formal
16adjudication of fraud or misrepresentation or in cases in which
17an insurer is acting as a plan administrator for the
18Comprehensive Health Insurance Plan under the Comprehensive
19Health Insurance Plan Act or, in cases in which the provider
20has already been paid in full, by any other payer, third party,
21or workers' compensation insurer. No contract between an
22insurer and a health care professional or health care provider
23may provide for recoupments in violation of this Section.
24Nothing in this Section shall be construed to preclude
25insurers, health maintenance organizations, independent
26practice associations, or physician hospital organizations

 

 

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1from resolving coordination of benefits between or among each
2other, including, but not limited to, resolution of workers'
3compensation and third-party liability cases, without
4recouping payment from the provider beyond the 18-month time
5limit provided in this subsection (c).
6(Source: P.A. 93-261, eff. 1-1-04.)